About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review
Wolverhampton review
CSP: WolverhamptonPublished: August 2023Year of death: 2019Extracted: 8 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The report identifies systemic missed opportunities by agencies to identify and address domestic abuse, self-harm, and substance misuse. There was a lack of a 'Think Family' approach, inadequate multi-agency coordination, and insufficient information sharing regarding the victim's complex vulnerabilities, particularly for an older adult not meeting Care Act thresholds.
Home Office classifications
39 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - alcohol misuse
Victim - substance misuse
Victim - mental ill health
Victim - anxiety
Victim - depression
Victim - self harm
Victim - suicidal thoughts
Victim - suicide attempts
Victim - had been a victim of an abuser before
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Children - present at homicide (including adult children)
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - was a carer
Perpetrator - carer for victim
Perpetrator - neurodiverse condition diagnosis
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to social services as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to mental health services as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - known to workplace (employer) as a domestic abuse perpetrator
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - community safety partnership recommendations
DHR process - identification of risk recommendation themes
DHR process - training recommendation themes
DHR process - policy recommendation themes
DHR process - multi agency working recommendation themes
DHR process - record keeping recommendation themes
DHR process - other recommendation themes
Extracted recommendations
8 recommendations pulled from the report · 5 matched to organisations in the index
Addressed to
Safer Wolverhampton Partnership | Wolverhampton Clinical Commissioning Group | Black Country Healthcare Foundation Trust | Royal Wolverhampton Trust
The DHR recommends that the Safer Wolverhampton Partnership seek assurances from the Wolverhampton Clinical Commissioning Group (CCG), the Black Country Healthcare Foundation Trust (BCHFT) and the Royal Wolverhampton Trust (RWT) that appropriate and safe questioning of patients around risk of domestic abuse (in-line with current NICE guidance) is now taking place and that a record confirming questioning has occurred is made on patient notes, regardless of outcomes.
Addressed to
Wolverhampton Clinical Commissioning Group | Black Country Healthcare Foundation Trust | Adult Social Care | Royal Wolverhampton Trust
The DHR recommends that the CCG, BCHFT, Adult Social Care and the RWT review policy and procedures and guidance and training to ensure that they can demonstrate that ‘Think Family’ principles inform practice and that professionals obtain where appropriate a detailed family history and explore a patient’s social situation.
Addressed to
Safer Wolverhampton Partnership | Wolverhampton Safeguarding Together | Public Health
The DHR recommends that the Safer Wolverhampton Partnership should seek an account from Wolverhampton Safeguarding Together and Public Health of their Review of service provision and pathways (both statutory, voluntary and third sector), which is aimed at improving early identification of need and preventing harm to vulnerable adults who may otherwise develop care and support needs and be at risk of abuse or neglect
Addressed to
Safer Wolverhampton Partnership | Wolverhampton Clinical Commissioning Group | Wolverhampton Safeguarding Together
The Safer Wolverhampton Partnership should seek assurances from the CCG and WST that the protocols for multi-disciplinary and concerns meetings would allow a professional to convene a meeting where an adult presented with similar needs to those of the victim in this case.
Addressed to
Wolverhampton MASH | Adult Social Care
The DHR recommends that the Wolverhampton MASH and Adult Social Care should identify how, following a safeguarding referral, an accurate understanding of any unresolved risks can best be shared and communicated to all agencies involved with that adult (and made available to those agencies that go on to work with an adult). This summary should be recorded and be easily accessible to relevant agencies, to reduce the risk of incomplete information sharing.
Addressed to
Wolverhampton Clinical Commissioning Group | Royal Wolverhampton Trust | Black Country Healthcare Foundation Trust
The DHR recommends that the CCG, RWT and BCHFT should consider refreshing guidance to their professionals concerning safety planning after a self-harm incident, informed by NICE Self Harm Clinical Guidance 133
Addressed to
Commissioners of mental health services in Wolverhampton
The DHR would recommend commissioners of mental health services in Wolverhampton should explore the feasibility of funding suicide prevention services for adults of any age who may self-harm or report suicidal ideation
The DHR would propose to Wolverhampton Safeguarding Together that the Learning & Improvement subgroup consider how best learning from this DHR, and particularly learning related to elder abuse and interfamilial violence, be communicated broadly to frontline professionals